By the 1930s, as the need for smallpox vaccine declined, so did the passion of anti-vaccine groups. The Anti-Vaccination League of America lost its voice when Charles Higgins died in 1929, as did the American Medical Liberty League when Lora Little died two years later. Massive programs promoting diphtheria vaccine in the 1930s and polio vaccine in the 1950s failed to incite anti-vaccine activity. It would be another fifty years, until the airing of DPT: Vaccine Roulette, before the nationwide anger spurred by state-enforced vaccination reemerged. But the fight against compulsory vaccination in court was far from over.
In the late 1960s and early 1970s, public health officials at the CDC decided to eliminate measles from the United States. Their method sparked a series of lawsuits.
In the first half of the twentieth century, measles caused thousands of hospitalizations and hundreds of deaths every year. With the invention of a vaccine in 1963—and buoyed by the virtual elimination of smallpox and polio—the CDC saw an opportunity. Because measles occurred primarily in school-aged children, health officials reasoned that the best way to eliminate it would be to mandate vaccine for school entry. A famous photograph at the time—and one shown on Vaccine Roulette—was that of the CDC’s Alan Hinman holding up a sign that read “No Shots, No School.”
The CDC picked an opportune moment to launch its attack. Although measles vaccine had caused a dramatic decline in the disease, immunization rates had become stagnant. And measles cases increased. In 1970, forty-seven thousand cases were reported. By 1971, the number had risen to seventy-five thousand.
In addition to state health officials, CDC efforts drew on two powerful political groups. The first was the Joseph P. Kennedy Foundation, the second was that of Betty Bumpers. Kennedy was the father of President John F. Kennedy and senators Robert and Edward Kennedy. He was also the father of Rosemary Kennedy. Severely retarded from birth, Rosemary was lobotomized in 1941 and institutionalized from 1949 until her death in 2005. Moved by her struggle, the Kennedy Foundation provided services for the mentally disabled. The foundation was interested in measles because the virus caused encephalitis in four thousand Americans a year, often resulting in permanent brain damage. At the time of the CDC initiative, Edward Kennedy was a senator from Massachusetts and his sister, Eunice Kennedy Shriver, was head of the U.S. Office of Economic Opportunity, created as part of Lyndon Johnson’s Great Society. Writing to governors and congressmen, the Kennedys used their considerable influence to promote the enactment and enforcement of local school-entry mandates.
Bumper sticker displayed by South Carolina public health officials in 1980. (Courtesy of Dr. Alan Hinman.)
Whereas the Kennedys provided an emotional impetus for school requirements, Betty Bumpers, wife of Arkansas senator Dale Bumpers, provided a financial one. Recruiting First Lady Rosalynn Carter to her cause, in the early 1970s Bumpers helped create a federally funded program called the Childhood Immunization Initiative that bought vaccines for children whose parents couldn’t afford them. Through her efforts, federal funding for vaccines increased from $5 million in 1975 to $17 million in 1976 to $23 million in 1977. In addition, in response to a deadly measles epidemic in the early 1990s, Betty Bumpers and Rosalynn Carter founded Every Child by Two (ECBT), a nonprofit organization. ECBT organizes educational programs in cities with low immunization rates and supports efforts to vaccinate children in Africa.
One result of these efforts was that the number of states requiring vaccines for school entry increased from twenty-five in 1968 to forty in 1974—a situation that provided a natural experiment to see whether school mandates worked. At first, they didn’t seem to: outbreaks of measles continued. The problem, it turned out, wasn’t that health officials didn’t have school-entry requirements; it was that they didn’t enforce them. But the tide was about to turn.
In 1976, during a massive measles outbreak in Alaska, state health officials informed parents that their children couldn’t come to school until they were immunized. Fifty days later, after more than seventy-four hundred students hadn’t complied, health officials excluded them from school. Within a month, fewer than fifty children remained unvaccinated and the epidemic ended.
In 1977, a measles epidemic occurred in Los Angeles County; thousands of children were infected, many suffered measles pneumonia, three had measles encephalitis, and two died. On March 31, the county health director declared that any child who had not had a measles vaccine by May 2 would not be allowed in school. When the deadline arrived, tens of thousands of students still hadn’t been vaccinated. As in Alaska, Los Angeles County parents soon realized that health officials weren’t kidding—fifty thousand children were barred from school. Within days, most were back with proof of immunity, again ending the epidemic.
Although events in Alaska and Los Angeles County were compelling, the most dramatic example of the power of school mandates occurred in Texarkana, a city that straddles the border between Texas and Arkansas. Between June 1970 and January 1971 Texarkana suffered 633 cases of measles. At the time of the outbreak, Arkansas required vaccines for school entry and Texas didn’t. Of the 633 cases, 608 (96 percent) occurred in Bowie County (the Texas side) and 25 (4 percent) occurred in Miller County (the Arkansas side).
By 1981, all fifty states had school immunization requirements. During the next two decades, with greater enforcement, the number of measles cases declined dramatically. In 1998, only eighty-nine cases of measles occurred in the United States, most imported from other countries.
Walter Orenstein was a young epidemiologist at the CDC during the 1977 measles outbreak in Los Angeles: “The school mandate [in Los Angeles] really changed everything,” he recalled. “That set the precedent for no shots, no school. The beauty of the school laws is that we didn’t have policemen forcing people against their will to be vaccinated. We just said if you are unwilling to be vaccinated, you can’t go to school.” Orenstein was drawing a legal distinction between compulsory vaccination, in which people who refuse are forcibly vaccinated, and mandatory vaccination, in which people who refuse are denied social privileges, like attending public school.
Despite the remarkable success of school mandates, the heavy hand of health officials provoked a backlash. Some parents couldn’t accept that their unvaccinated children could be denied an education. So they sued the states, claiming protection under the First Amendment, which requires that “Congress shall make no law respecting an establishment of religion or prohibiting the free exercise thereof....” The ruling that tipped the balance in these First Amendment cases wasn’t the Supreme Court ruling in Jacobson or Zucht. It was one that on its surface had nothing to do with vaccines.
On December 18, 1941, Sarah Prince, a Jehovah’s Witness, took her two sons and nine-year-old niece, Betty Simmons, “to engage in the preaching work with her upon the sidewalks.” Prince had been warned by a school-attendance officer that bringing children with her at night violated state labor laws, but she ignored the warning. At 8:45 p.m., “Betty held up in her hand, for passers-by to see, copies of ‘Watchtower’ and ‘Consolation.’ From her shoulder hung the usual canvas magazine bag.” The truant officer again warned Prince to get the children off the street. “Neither you nor anyone else can stop me,” threatened Prince. “The child is exercising her God-given right and her constitutional right to preach the gospel, and no creature has a right to interfere with God’s commands.” The case, known as Prince v. Massachusetts, reached the U.S. Supreme Court in 1943, and in January 1944 the court ruled against Prince, arguing that religious freedom didn’t trump child-labor laws. Justice Wiley B. Rutledge, who wrote the majority opinion for the court, then went beyond the case in front of him: “The right to practice religion freely does not include liberty to expose the community or the child to communicable disease or the latter to ill health or death. Parents may be free to become martyrs themselves, but it does not follow that they are free, in identical circumstances, to make martyrs of their children.”
The ruling
had a major impact on vaccine lawsuits. In 1965, the Wrights, members of the General Assembly and Church of the First Born, argued unsuccessfully that DeWitt High School in Arkansas County, Arkansas, had violated their right to exercise their religion by requiring a smallpox vaccine for their children. In 1968, Thomas McCartney, a chiropractor and Roman Catholic, argued unsuccessfully that school officials in Broome County, New York, had violated his religious freedom by requiring a polio vaccine for his ten-year-old son. In 1974, Ronald Avard argued unsuccessfully that the public school system in Manchester, New Hampshire, had violated his religious freedom by dismissing his unvaccinated six-year-old son from kindergarten. In 1979, Charles Brown, a chiropractor and member of the Church of Christ, argued unsuccessfully that the school board in Houston, Mississippi, had violated his religious freedom by dismissing his unvaccinated six-year-old son from first grade. In 1982, Irving Davis, a member of the Church of Human Life Science, argued unsuccessfully that school officials in Cecil County, Maryland, had violated his religious freedom by not allowing his unvaccinated eight-year-old son to enter school.
The judges in each of these cases ruled that the right to practice religion freely hadn’t been violated because vaccination was required of all religions, without discrimination. However, a little-publicized bill in New York State had already opened a crack in the door—a crack that would have a major impact on the spread of contagious diseases in the United States. On June 20, 1966, New York State assemblymen voted on a bill requiring polio vaccine for school entry. There was one catch. The bill excluded children whose parents’ religion forbade vaccination, a direct result of lobbying by what was then one of the most powerful religious groups in the United States: Christian Scientists. The bill passed by a vote of 150 to 2. One of the dissenters, Joseph Margiotta, later explained his reasoning. “Suppose an exempted child was a polio carrier,” he said. Margiotta’s concern proved prescient.
Founded in 1879 by Mary Baker Eddy, Christian Scientists believed that illness was a mental, not physical, disorder. In her book Science and Health, Eddy wrote, “We have smallpox because others have it, but mental mind, not matter, contains and carries the infection.” Diseases like smallpox could be avoided by prayer, not by vaccines. Those who chose to follow Eddy’s teachings have paid the price.
In 1982, nine-year-old Debra Kupsh died of diphtheria at a Christian Scientist camp in Colorado. In 1985, three students died of measles at Principia College, a Christian Scientist school in Elsah, Missouri. At the time, the CDC’s Walter Orenstein noted that the high rate of measles deaths at Principia resembled “the kind of mortality statistics we see in the Third World.” The 1985 outbreak wasn’t the end of it; four more measles outbreaks occurred among Christian Scientist students in the St. Louis area between 1985 and 1994.
But the incident that attracted the most attention occurred in the fall of 1972, when a Christian Scientist high school in Greenwich, Connecticut, suffered a polio outbreak. Eleven children were paralyzed. At the time of the outbreak, not a single case of polio had occurred in Connecticut in more than three years. One health commissioner was so shaken that he wrote an editorial in the New England Journal of Medicine: “Although I am not arguing for absolute state control of the lives of private citizens, I am deeply bothered by the fact that disease prevention measures of documented benefit can be withheld from children by their parents in the name of religious freedom, jeopardizing not only the health and lives of the children so denied but those of the community as well. The courts of this land have long since set precedent in the protection of children from the irresponsible acts of their parents.”
The successful lobbying of Christian Scientists to include a religious exemption in New York State changed the strategy of those who wanted to avoid vaccines. Two seminal rulings opened the floodgates. The first involved William Maier and his three children—all of whom had been excluded from Fabius Central School in Onondaga County, New York. Maier argued that, although he wasn’t a Christian Scientist, he, like they, believed that “the sanctity of the human body cannot be violated by injection,” and that his beliefs were entitled to the same protection as a Christian Scientist’s. The judge agreed. The second ruling allowing religious exemptions involved Beulah Dalli, a mother in Lowell, Massachusetts. Dalli argued that her six-year-old daughter, Belinda, had been unfairly excluded from school because she wasn’t vaccinated. Although Dalli, like Maier, wasn’t a Christian Scientist, she believed that the use of vaccines was a violation of the Bible and its teachings, specifically the admonition to “keep the body clean and acceptable to God.” The court ruled in her favor, stating that it was unfair to allow vaccine exemptions for some religious groups but not others. By 2009, forty-eight states allowed religious exemptions to vaccination.
Religious exemptions opened the door to philosophical exemptions. A critical ruling in the late 1980s involved two Northport, New York, couples: the Sherrs and the Levys. Alan Sherr, a chiropractor, argued that his religion—a mail-order church in Sarasota, Florida, called the Missionary Temple at Large of the Universal Religious Brotherhood, Inc.—believed that vaccines represented an unwanted intrusion into the body. However, because Sherr had circumcised his son and allowed dentists to fill his son’s cavities, the intrusion argument didn’t hold. The Levys, on the other hand, were more compelling. Louis Levy argued that the state should not be allowed to force his daughter, Sandra, to be vaccinated because “We feel that any introduction into the process of a foreign element outside the normal processes of the body is going to affect the body adversely and, therefore, we feel it is a violation in a sense of our nature—physical, spiritual, religious nature.” The judge ruled in Levy’s favor, stating that vaccine exemptions could be granted if “beliefs [were] held with the strength of religious convictions,” even if parents weren’t members of a religious group. By 2010, twenty-one states allowed philosophical exemptions to vaccination.
By the late 1890s, the anti-vaccine movement in England had spawned the Anti-Compulsory Vaccination Act. If citizens didn’t want to be vaccinated, they could obtain a certificate of conscientious objection. As more and more citizens opted out, England became the United Kingdom’s epicenter of smallpox disease. By the early twenty-first century, American anti-vaccine activists—through passages of religious and philosophical exemptions—had also impacted the public’s health. Between 1999 and 2009, four studies examined whether the freedom to avoid vaccines also meant the freedom to catch and transmit infections.
In 1999, Daniel Salmon and co-workers from the Johns Hopkins School of Public Health found that the risk of contracting measles in five- to nine-year-olds whose parents had chosen not to vaccinate them was one hundred and seventy times greater than for vaccinated children.
In 2000, Daniel Feikin and his colleagues from the Respiratory Diseases Branch at the CDC found that three- to ten-year-olds in Colorado whose parents had chosen not to vaccinate them were sixty-two times more likely to catch measles and sixteen times more likely to catch whooping cough. They also found that measles outbreaks were more common in schools with greater numbers of unvaccinated children.
In 2006, Saad Omer and his colleagues, also from the Johns Hopkins School of Public Health, examined the impact of philosophical exemptions. Between 1991 and 2004, the number of unvaccinated children in states with philosophical exemptions more than doubled. Children in states with easy-to-obtain exemptions (granted by the simple signing of a form) were almost twice as likely to suffer outbreaks of whooping cough.
In 2009, Jason Glanz and his co-workers from the Institute for Health Research in Denver—confirming previous studies—found that unvaccinated children in Colorado were twenty-three times more likely to suffer whooping cough.
The impact of anti-vaccine activism hasn’t been limited to England and the United States. Studies have shown that the risk of whooping cough was ten to a hundred times greater in countries where immunization had been disrupted by anti-vaccine movements (such as Sweden, J
apan, the Russian Federation, Ireland, Italy, and Australia) than in countries that had maintained high vaccination rates (such as Hungary and Poland).
The results were in. A choice not to get a vaccine was a choice to increase the risk of suffering and possibly dying from an infectious disease. Worse still, it was a choice to put one’s neighbor at greater risk. So why are more and more parents choosing not to vaccinate their children? The answer can be found in part in the writings of a professor of biology at the University of California at Santa Barbara who has explained why, under certain circumstances, a choice not to get a vaccine is far more rational than a choice to get one.
In 1968, Garrett Hardin published an essay in the journal Science called “The Tragedy of the Commons.” Hardin was interested in the problem of population control, but his observations can easily be applied to the problem of vaccine refusal. “Picture a pasture open to all,” he wrote. “It is to be expected that each herdsman will try to keep as many cattle as possible on the commons. As a rational being, each herdsman seeks to maximize his gain. He asks, ‘What is the utility to me of adding one more animal to my herd?’ The utility has one negative and one positive component.”
Hardin continued: “The positive component is a function of the increment of one animal. Since the herdsman receives all the proceeds from the sale of the additional animal, the positive utility is nearly +1. The negative component is a function of the additional overgrazing created by one more animal. Since, however, the effects of overgrazing are shared by all the herdsmen, the negative utility for any particular decision-making herdsman is only a fraction of -1.”
Deadly Choices: How the Anti-Vaccine Movement Threatens Us All Page 16
